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REVIEW

URRENT
C
OPINION

Malnutrition screening tools for hospitalized


children
Corina Hartman a, Raanan Shamir a, Christina Hecht b, and Berthold Koletzko b

Purpose of review
Malnutrition is highly prevalent in hospitalized children and has been associated with relevant clinical
outcomes. The scope of this review is to describe the five screening tools and the recent European Society
for Parenteral and Enteral Nutrition (ESPEN) research project aimed at establishing agreed, evidence-based
criteria for malnutrition and screening tools for its diagnosis in hospitalized children.
Recent findings
Five nutrition screening tools have recently been developed to identify the risk of malnutrition in
hospitalized children. These tools have been tested to a limited extent by their authors in the original
published studies but have not been validated by other independent studies. So far, such screening tools
have not been established widely as part of standard pediatric care.
Summary
Although nutrition screening and assessment are recommended by European Society for Parenteral and
Enteral Nutrition and the European Society for Pediatric Gastroenterology Hepatology and Nutrition and
are often accepted to be required by healthcare facilities, there is no standardized approach to nutritional
screening for pediatric inpatients. The near future will provide us with comparative data on the existing
tools which may contribute to delineating a standard for useful nutrition screening in pediatrics.
Keywords
children, nutritional assessment, nutritional screening, screening tools, undernutrition

INTRODUCTION
The European Society for Clinical Nutrition and
Metabolic Care (ESPEN) (www.ESPEN.org) defines
malnutrition as a state of nutrition in which
a deficiency or excess (or imbalance) of energy,
protein, and other nutrients causes measurable
adverse effects on tissue/body form (body shape,
size and composition) and function, and clinical
outcome [1]. This definition is aimed at emphasizing that malnutrition is a disease with adverse
consequences on body composition and function,
and not just a change of body shape or appearance.
To prevent malnutrition and, especially,
hospital-acquired malnutrition, the risk of nutritional depletion needs to be identified as soon as
possible, best at admission, so that appropriate nutritional intervention can be initiated at an early stage.
Routine nutritional screening is rarely carried out in
pediatric patients because of the lack of a simple and
properly validated nutritional screening tool.
The current practice of identifying children
at risk of malnutrition is heavily reliant on the
interpretation of anthropometric data and clinical

judgment, the reliability of which is dependent


on pediatric nutrition knowledge, usually of a pediatrician or registered pediatric dietitian. Severe cases
of malnutrition are relatively easily recognized;
however, the identification of children with mild
or moderate malnutrition or at risk of malnutrition,
which is also very important, is not as easily
achieved.

a
Institute of Gastroenterology, Nutrition and Liver Diseases, Sackler
Faculty of Medicine, Tel-Aviv University, Schneider Childrens Medical
Center of Israel, Clalit Health Services, Petach Tikva, Israel and bDivision
of Metabolic and Nutritional Medicine, Dr von Hauner Childrens Hospital,
Ludwig-Maximilians-University of Munich, Munich, Germany

Correspondence to Corina Hartman, Institute of Gastroenterology,


Nutrition, and Liver Disease, Schneider Childrens Medical Center of
Israel, 14 Kaplan Street, Petach-Tikva 49202, Israel. Tel: +972 3
9253672; fax: +972 3 9253104; e-mail: corinahartman@gmail.com
Curr Opin Clin Nutr Metab Care 2012, 15:303309
DOI:10.1097/MCO.0b013e328352dcd4

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Paediatrics

KEY POINTS
 In the absence of agreed and evidence-based criteria
for the diagnosis of malnutrition and risk for
malnutrition, nutrition assessment and timely
intervention are not yet adequately incorporated into
the routine of pediatric hospital care.
 Further data are needed to define the consequences of
different markers of child undernutrition on outcome, to
derive evidence-based criteria for malnutrition and
cutoffs for further diagnostic and therapeutic
interventions.
 Several screening tools have been proposed for the
assessment of nutritional status and risk in hospitalized
children, but none of them has been sufficiently
validated and generally accepted for broad use.
 Evidence-based implementation of a simple and reliable
nutrition risk screening tool appears highly desirable to
advance the early and cost-effective identification of
children who will benefit from targeted nutritional
intervention.

MALNUTRITION IN HOSPITALIZED
PEDIATRIC PATIENTS
The reported prevalence of acute malnutrition
in infants and children admitted to hospitals from
different countries ranges from 6.1 to 40.9% [212].
In children with an underlying disease, higher
prevalence of chronic malnutrition (4464%) was
reported in several studies [13 ,1418], including a
recent study demonstrating a prevalence of 90% in
children with congenital heart defect [16].
The reasons for such differences within the
reported rates of malnutrition in hospitalized
children are multiple: heterogeneity of assessors
and data collection; the inconsistency of definitions
used to classify nutritional status; and the diversity
of the study population, type of institution and
country of recruitment.
Undernutrition in childhood has been associated with poor growth, reduced educational and
social achievements and possible implications
for adult health and performance [19,20 ,21].
Malnutrition in hospitalized children is a highly
relevant pathologic condition and a risk factor
for unfavorable outcome, prolonged hospital stay,
delayed recovery and increased care costs [2225].
&

&

CLINICAL JUDGMENT, ANTHROPOMETRY


OR NUTRITION HISTORY?
The value of clinical judgment alone for identifying
nutrition risk is debatable and has been found
uniformly poor in the absence of anthropometric
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measurements [26,27]. Anthropometric measurements, such as weight and height, and the interpretation of these, are an objective and quantitative
element of nutritional assessment. Traditionally,
acute undernutrition in children has been defined
as low weight-for-age or low weight-for-height
(wasting), and chronic undernutrition has been
classified on the basis of low height-for-age (stunting) as described by Waterlow [28]. Indices derived
from percentage weight-for-height have been
developed, but these require more calculations
and a certain degree of competence in dealing
with growth charts. The accuracy of these calculations, even when undertaken by experienced
professionals, has been questioned. Several studies
and reviews have shown that the classification of
nutritional status in children is highly dependent
on the criteria and cut-off values used to categorize
undernutrition [12,29,30].
Anthropometric assessment using weight and
height is generally considered to be a basic requirement of the admission process. However, in clinical
practice, many limitations exist [31]. A lack of functioning, calibrated and fit-for-purpose equipment
is common [32,33]. When equipment is available,
the technique used to obtain measurements is
not always standardized and the recording of
measurements is often poor, if done at all [34 ].
The information that can be derived from single
measurements is limited because growth rates differ
between children and with the developmental stage.
In view of these difficulties, use of anthropometric
indices or one of the classification methods to
define nutritional status and the risk of malnutrition
in hospitalized children is currently less than
satisfactory.
The assessment of energy intake is considered
as a key part of the nutritional assessment.
Indeed, reduction of dietary intake, together with
the increase of energy requirements, is the main
cause of hospital undernutrition and can contribute
to its worsening. The subjective assessment of
dietary intake by the patient himself/herself is
included in several nutritional indices in adults,
such as the Subjective Global Assessment (SGA),
the Mini Nutritional Assessment (MNA) or the
Nutritional Risk Score (NRS) [35]. A poor nutrient
intake was associated with a higher rate of infections, poor wound healing, more frequent cardiac
complications and even increased mortality [36,37].
From a clinical point of view, the availability
of methods allowing a quick assessment of daily
energy intake would be of utmost interest also in
children.
The NutritionDay project is an ESPEN supported 1-day, cross-sectional audit of nutritional
&&

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Malnutrition screening tools in pediatrics Hartman et al.

status and food intake primarily in hospitalized


adults followed by an outcome evaluation 30 days
later, which is performed yearly across many
European hospitals. During NutritionDay 2006, a
history was obtained from 14 665 (90%) participants, and individual information about actual food
intake was obtained from 14 474 (89%) patients.
Individual food intakes on NutritionDay revealed
that less than half of all patients finished their
meals. In this single-day audit of food intake, even
when taking into account other variables, a progressive increase of 30-day mortality was associated
with decreased food intake [37].
Insufficient nutritional intake in hospital was
addressed in 2003 by a resolution from the European
Council; and in 2006 by guidelines from UKs
National Institute for Health and Clinical Excellence
(NICE): however, it is unknown by now whether
these initiatives will have impact on nutrition care
in European hospitals [38,39].

PEDIATRIC NUTRITION SCREENING TOOLS


National and international health organizations
have recommended that all adults should have
their nutritional status assessed and screened for
nutrition risk at any encounter with health services
[40,41]. For this purpose, nutrition risk screening
tools have been designed for the early identification
of malnutrition or undernutrition by staff who are
not expert in nutrition [35]. These screening tools
have been validated in a variety of clinical settings
and with different patient groups. However, none of
these adult tools are validated for use in children.
The reasons are multiple but mainly the difficulty to
assess improper growth, the pediatric equivalent to
adult weight loss based on one weight or height
measurement. In addition, the clinical implications
of diseases are different for children, the underlying
cause and pathology differ in some instances, and
the impact of disease on growth and subsequent
development is an additional important complicating factor.
In order to improve nutritional care in pediatric
hospitals, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (www.
ESPGHAN.org) Committee on Nutrition has recommended the establishment of nutrition support
teams whose tasks should include among others
identification of patients at risk of malnutrition,
provision of adequate nutritional management,
education and training of hospital staff and audit
of practice. However, these recommendations have
not been widely introduced into routine clinical
practice [42]. During the last few years, impressive
efforts have been made to create simple and useful

nutrition screening tools for children. The scope


of this review is to describe these tools and
the recent ESPEN research project aimed to link
anthropometric measurements to outcome (e.g.
length of hospital stay), to establish broadly
agreed, evidence-based criteria for malnutrition
in children and to put forward an evidence-based
screening tool for pediatric malnutrition and malnutrition risk.
At least five malnutrition screening tools have
been developed in the last decade to address the risk
of malnutrition in hospitalized children (Table 1).
These tools have been tested by their authors in
the original published studies, without having
been properly validated in larger cohorts or by other
authors. Furthermore, there is no documentation
of the impact of screening tools implementation
with respect to overall benefit and cost, an essential
prerequisite for inclusion of these tools in routine
pediatric care.
Sermet-Gaudelus et al. [43] developed and tested
a screening tool based on prospective nutritional
assessment and a weight loss greater than 2% from
admission weight as the cut-off for nutrition risk.
Nutritional risk was assessed prospectively in 296
children by evaluating various factors within 48 h
of admission. Multivariate analysis indicated that
food intake less than 50%, pain, and grade 2 and
3 pathologic conditions (P 0.0001 for all) were
associated with weight losses of greater than 2%.
The Pediatric Nutritional Risk Score (PNRS) ranged
from 0 to 5 and was calculated by adding the values
for the significant risk factors as follows: 1 for food
intake less than 50%, 1 for pain, 1 for grade 2
pathologic condition and 3 for grade 3 pathologic
condition. A score of 1 or 2 is supposed to indicate
moderate risk and a score of at least 3 to indicate
high risk of malnutrition. Although this tool
appears to be quick and simple to use, the study
does not detail on the conditions required for
implementation (e.g. staff training and resources)
or the reliability and the reproducibility of the tool
in practice.
Secker and Jeejeebhoy [44] developed and
tested a Subjective Global Nutritional Assessment
(SGNA) score for children. The SGNA consisted
of a nutrition-oriented physical examination and
information on the childs recent and current height
and weight, parental heights, dietary intake, frequency and duration of gastrointestinal symptoms,
current functional capacity and recent changes.
The SGNA was tested on a population of children
undergoing surgery, and the occurrence of nutrition-associated complications was documented
at 30 days after surgery. SGNA divided children
into three groups: well nourished, moderately

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Table 1. Pediatric nutrition screening tools for hospitalized children
Population/setting
Screening tool

Number, age, range

Content/items

Comments

Pediatric nutritional
risk score

Medical/surgical

Food intake (1)

Nutritional risk

Sermet-Gaudelus
et al. [43]

296 Children

Difficulty with retaining food

Weight loss >2%

15 months

Pain (1)

Food intake <50%

(1 month?)

Ability to eat

Severe pathology

Medical condition (1/3)

Moderate risk 1/2


High risk 3

Subjective Global
Nutrition Assessment

Surgical

Weight history

Malnourished children had


poorer outcomes:

Secker and
Jeejeebhoy[44]

175 Children

Parental height

Infections

15 Months

Dietary intake

Longer LOS

(1 month17.9 years)

Gastrointestinal symptoms
Functional capacity
Physical examination
Underlying condition

STAMP

Medical/surgical

Clinical diagnosis

McCarthy et al. [45]

89 Children (217 years)

Nutritional intake

STAMP showed 72% sensitivity


and 90% specificity compared
to full nutritional assessment

Anthropometry
PYMS

Medical/surgical

BMI (02)

Compared to Dietitian assessment


PYMS

Gerasimidis
et al. [46]

247 Children

Recent weight loss (02)

Sensitivity (%) 59

Nutritional intake (02)

Specificity (%) 92

Medical condition (02)

PPV (%) 47
NPV (%) 95

STRONGkids

Academic/general

Subjective assessment (1)

Children at risk (score 4/5)

Hulst et al. [47]

424 Children

High-risk disease (2)

Lower SD scores W/H (P < 0.001)

Nutritional intake (1)

Longer LOS (P 0.017)

3.5 years (1 month17.7 years)

Weight loss (1)


LOS, length of stay; NPV, negative predictive value; PPV, positive predictive value; PYMS, Pediatric Yorkhill Malnutrition Score; STAMP, Screening Tool for the
Assessment of Malnutrition in Pediatrics; STRONGkids, Screening Tool Risk on Nutritional status and Grow.

malnourished and severely malnourished. The


children categorized as malnourished had a higher
rate of infectious complications and a longer postoperative length of stay than the well nourished
children. Although this is so far the only pediatric
tool that correlated nutritional status categories
with outcome, one of the limitations of SGNA use
in clinical practice may be the time required to
complete it. Although referred to as a screening tool,
the name acknowledges that the SGNA is more a
structured nutritional assessment. The authors did
not report the time taken to complete the SGNA
or the level of training and expertise in nutrition
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assessment of the assessors. These are critical


considerations that require clarification.
STAMP Screening Tool for the Assessment of
Malnutrition in Pediatrics is a 5-step tool that was
tested in comparison to a full nutritional assessment
in a group of 89 children aged 217 years admitted
for surgery [45]. STAMP consists of three elements:
clinical diagnosis (classified by the possible nutritional implications), nutritional intake and anthropometric measurements (weight). Each element is
scored and nutritional risk is translated into the
need for a referral for full assessment. No outcomes
were evaluated with the STAMP tool.
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Malnutrition screening tools in pediatrics Hartman et al.

The Paediatric Yorkhill Malnutrition Score


(PYMS) assesses four steps considered as predictors
or symptoms of malnutrition: BMI, history of recent
weight loss, changes in nutritional intake and the
predicted effect of the current medical condition on
the nutritional status of the patient [46]. Each step
bears a score of up to 2, and the total score reflects
the degree of the nutrition risk of the patient. Of
the 247 children studied, the nurse-rated PYMS
identified 59% of those rated at high risk by full
dietetic assessment. Of those rated at high risk by
the nursing PYMS, 47% were confirmed as high risk
on full assessment. These results can be interpreted
that at least half of children were inadequately
referred to dietitians for evaluation, and almost
40% were missed by the nurse-administered PYMS,
but most of these children would not have been
identified at all without PYMS. As has been shown
by earlier studies, health staff are poor at recognizing
undernutrition [26,27]. The fact that use of PYMS
by a dietitian identified more true cases also suggests
that the diagnostic accuracy of the PYMS might
possibly be improved by further training and
continuous use. The authors also performed a comparison of screening tools with research dietitians
assessment. SGNA had the highest specificity and
positive predictive value, but very low sensitivity,
which might not be surprising considering that the
SGNA is rather an assessment method than a screening tool. The PYMS identified all the children who
screened at high risk by the SGNA, but only 52% of
those screened at high risk by the STAMP. Likewise,
the STAMP and the PYMS completed by the research
dietitians both achieved high specificity and sensitivity, but the positive predictive value was higher
for the PYMS which also showed higher agreement
with the research dietetic assessment.
STRONGkids Screening Tool Risk on Nutritional status and Growth has been developed and
tested in a multicenter study that included 424
children aged 3.5 years (range 31 days to 17.7 years)
admitted to seven academic and 37 general hospitals in the Netherlands [47]. The STRONGkids
screening tool consists of four elements: subjective
clinical assessment, high-risk disease, nutritional
intake and weight loss or poor weight gain. Measurements of weight and length were also performed. SD
scores of 2 or less for weight-for-height and heightfor-age were considered to indicate acute and
chronic malnutrition, respectively. The study data
show a significant relationship between high-risk
score in STRONGkids and weight for height z-score.
In addition, the length of hospital stay was significantly different between the lowest and highest
risk groups. The authors claim great simplicity
with the use of their screening tool; however, the

STRONGkids has two weak points: the subjective


clinical assessment item was carried out by skilled
pediatricians, whereas one would ideally wish for a
screening tool that can be applied by all healthcare
workers; the 4th item weight loss or poor weight
gain or anthropometric indices calculation require
either previous knowledge of the child weight/
length (rarely available beside infancy) or timeconsuming assessment and interpretation of these
indexes.

FUTURE CONSIDERATIONS
None of the tools described above were validated
in larger study populations beyond the first
publication setting. Most of these screening tools
have not been correlated with clinical outcome or
have weaknesses that may be a barrier for using
them as universal screening tools. Assessment of
the consequences of implementing any of these
tools in pediatric clinical routine practice, including
potential benefit and burdens for the patients
and their families as well as health and economic
consequences, is not available.
A research project to address some of the open
questions is currently being performed with support
by a Network Grant of ESPEN and in collaboration
with the Working Group on Malnutrition of the
ESPGHAN. This mutlticenter study coordinated by
Professor Berthold Koletzko, Munich, Germany, is
performed in 14 pediatric departments in 12
European countries. Demographic and medical data
were collected in over 2400 pediatric inpatients.
Anthropometric measurements and interviews were
performed during the first 24 h after admission, and
outcome data were collected after discharge. The
initial interview included the questions of three previously proposed screening tools: STAMP, PYMS and
STRONGkids. The results of this project will help to
establish the criteria to link anthropometric measurements with outcomes such as length of hospital stay.
Hopefully, it will lead to agreed, evidence-based
criteria for malnutrition in children and provide
further information on possible selection of an
appropriate screening tool for children.

CONCLUSION
Proper assessment of nutritional status should be
a standard requirement of child care aimed to
identify those patients who can benefit from and
need targeted intervention. Nutritional assessment
should provide reliable information on the childs
nutritional status, a risk assessment of future development of underweight or overweight, and the basis for
decisions on further diagnostic steps, monitoring

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Paediatrics

and therapeutic interventions. The purpose of nutritional screening, that should precede detailed assessment, is to identify children at risk for inadequate
nutritional intakes or occurrence of undernutrition,
and thus to select children who should receive a
more detailed nutritional assessment. Any pediatric
nutrition screening tool for broad use should be
rapid and easy to use by admitting staff or community healthcare teams without the need of
involving qualified nutrition experts. The ideal
screening tool should consist of a few easily obtainable data points, which might include both objective
(anthropometry) and subjective (disease state/food
intake/nutrition history) data. Any tool designed
to become part of the routine pediatric assessment
should be well reproducible, have good sensitivity
and specificity with regard to significant health
outcomes, support the cause of child nutrition on
a larger scale and be cost-effective. We hope that
additional information on the potential strengths
and limitations of existing tools will become
available in the near future, which may contribute
to delineation of broadly agreed standards for useful
nutrition screening in pediatrics.
Acknowledgements
This work was financially supported in part by a Network
Grant of the European Society of Clinical Nutrition and
Metabolic Care (www.espen.org). Additional financial
support by the Munich Centre of Health Sciences
(McHealth) and the Child Health Foundation (www.
kindergesundheit.de) is gratefully acknowledged. B.K.
is the recipient of the Freedom to Discover Award of
the Bristol Myers Squibb Foundation, New York, NY,
USA. The authors are most grateful indeed for the active
contributions of the further partners of the multicentric
ESPEN Network Grant study, Carlo Agostoni, Milano;
Carmen Culcitchi, Cluj-Napoca; Diana Flynn, Glasgow;
Frederic Gottrand, Lille; Koen Joosten and Jessie Hulst,
Rotterdam; Harma Koetse, Groningen; Sanja Kolacek,
Zagreb; Janusz Ksiazyk, Warsaw; Peter Sullivan,
Oxford; and Hania Szajewska, Warsaw.
Conflicts of interest
There are no conflicts of interest.

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